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IB002

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9 Floor, Bangunan AMBD, No.1, Jalan Lumut, 50400 Kuala Lumpur, Malaysia. GPO Box 10956, 50730 Kuala Lumpur
Tel: (603) 4043 2100 Fax: (603) 4043 8680
To: The Manager From:
Claims Department - Life
Head Office

CLAIMS NOTIFICATION ADVICE

HEAD OFFICE USE ONLY


Policy No :
Claim No :
Date Of Notification : Date Received :

Name Of Policy Owner :


Name Of Life Assured :
(If different from policyowner)
Correspondence Address :

Tel No’s: House : ____________________________ 0ffice :


Mobile No : _________________________

TYPE(S) OF CLAIM (Please tick where applicable)

Death Claim Hospitalisation Benefit Claim

Total & Permanent Disability Claim Hospitalisation & Surgical Claim

Critical Illness Claim Accident Benefit Claim

Payor Benefit Claim Maternity Benefit Claim

Other Types Of Claim, please specify


Date of event leading to this claim
Cause of event leading to this claim
Name of person notifying this claim
This notification serves as an official notification for the happening of an event leading to the above claim.

Please forward the necessary documents to __________________________________________

We shall forward the necessary claim documents to you soon as possible.

Thank you

____________________
Signature

Name :____________________________
Designation : ____________________________

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